GRANDE ICU CASE SUMMARY

Patients Name: TIL KUMARI SHARMA Age/Sex: 60 Years/Female

Hospital no:16010663 IP No: 14696
Address: Butwal
Date of ICU Admission:06/04/ 2016
Consultant: Prof. Dr. Arjun Karki / Dr. Subhash P. Acharya
Neurosurgery: Dr. Amit Thapa

Diagnosis on ICU Admission:

1. COMMUNITY ACQUIRED PNEUMONIA

2. POST CRANIOTOMY STATUS FOR MENINGIOMA (2016/3/7)

CaseSummary:
60 years female known case of HTN, presented with the history of s/p craniotomy for
meningioma (done on 2016/3/7) presented in GIH ER with history of altered sensorium since 4
days. The patient was drowsy and unresponsive. There was history of fever with cough with
purulent productive cough with poor expectoration effort since 3 days. The patient also had
history of occasional difficulty in breathing. There is also gave history of bilateral leg swellings
since 2 days.
There is no h/o chest pain, vomiting, altered bowel and bladder habits or burning
micturition, or seizure like activity.
The patient was initially taken to Neuro hospital and Gangalal hospital then to KMCTH
and was said to have chest infection and was being treated at home. The patient was
brought to GIH on 6/4/2016 due to increased unresponsiveness, for further evaluation and
management.
No past history of DM, TB
Past surgical history of craniotomy for Meningioma (done on 2016/3/7)

Assessment on ICU Admission:

Neurology: GCS: E4V4M6 Pupil: B/L equal & reactive to light, orientation (-), response (+)
Respiratory: Chest b/l equal air entry, no added sounds. RR: 13/min SpO2: 93%
CVS: Afebrile (36.2C), S1 S2 Mo, HR 90/min, BP: 99/61 mmHg
GI: Soft, No organomegaly, BS (+)
G/U: Foleys catheter insitu.
Lines: Peripheral line +, right hand
Course inHCU/ ICU:

Patient was admitted in HCU for further management. Pulmonology review was done and advice
to continue antibiotics (Inj Tazopip, Inj Azithromycin, Inj Clindamycin) and other supportive
treatments was made. Treatment for pneumonia was continued. Meanwhile CT scan head was
done and MRI of head was also done . Pulmonary embolism was ruled out. Other supportive
therapy was continued.

On 10/4/2016 at 6am the patient started having jerky movements of left hand and left leg,
antiseizure medication was given accordingly, Patient still had persistant jerky movements,
seizure not controlled so she was shifted to ICU for control of seizure. The patient was intubated
and Propofol infusion was started for seizure control, with Mechanical ventilation setting kept at
VT- 400, RR- 18/m, PEEP- 5, FIO2- 40%. (as patient had Status Epilepticus)

Antiseizure medication was adjusted according to Neuromedicine consultation and review. The
Propofol infusion was tapered off gradually and the patient was extubated on 17/04/2016. Her
antiseizure medication was also gradually adjusted accordingly.

Assessment as per Date:

Neuro: GCS: E4V2M6, Pupil: B/L equal , reactive to light, orientation (+), response (+)
Respiratory: Chest b/l equal air entry,wheeze + RR: 24/min SpO2: 99% in 40% venturi mask
CVS: afebrile (36.5. C), S1 S2 Mo, HR 119/min, Rhythm: Sinus Regular, BP: 128/64 mmHg
GI: Soft, BS (+)
G/U: Foleys catheter insitu, input /output=2800ml/2640ml.
Lines: Peripheral line +, arterial line + in left radial artery

Relevant Investigations:

MDCT head 6/4/2016 : Calvarial defect in left frontoparietal region with a hypodense area in left
frontal lobe likely post surgical . Minimal collection in scalp overlying the calvarial defect.

Portable echo on 7/4/2016: normal LV systolic function, mild MR, mild TR.

Bilateral Lower Limb venous droppler on 7/4/2016: no evidence of DVT

MRI brain 9/4/2016: approx 2.7 x2.8 x3.2 cm (APXTRXCC) size cavity in left frontal lobe with
predominantly fluid signal intensity inside with peripheral part containing bllod products. Mild
enhancement in superior peripheral part of this cavity suggestive of post op changes.Less likely
to be residual/recurrent tumor. T2w and FLAIR hyperintensities in b/l deep white matter without
restriction on DWI likely to be nonspecific. Retained secretions in sphenoid sinus.

EEG on 15/4/2016: abnormal EEG showing BIPLEDS

Final Diagnosis:

1. COMMUNITY ACQUIRED PNEUMONIA (RESOLVED)

2. POST CRANIOTOMY STATUS FOR MENINGIOMA (2016/3/7)
3. STATUS EPILEPTICUS PARTIALIS CONTINUA (CONTROLLED WITH
MEDICATION)

Current Medications:

1. INJ LEVERA 1.5 GM IV Q 12 HOURLY

2. INJ SOD VALPORATE 1GM IV Q 12HRLY
3. INJ PHENYTOIN 50MG IV Q12 HRLY THEN Q 24 HRLY X 3DAYS
4. INJ CLEXANE 60MG S/C Q 24HRLY
5. INJ DEXONA 2MG IV Q 6HRLY
6. INJ ACILOC 50MG IV Q 8HRLY
7. TAB CARBAMAZIPINE 400MG OG Q 12HRLY

.
Dr Anuj Dahal Dr Sabin Koirala, MD Dr Subhash P Acharya MD, FACC,
Medical officer Registrar, Anaesthesiology Consultant, Intensivist
Email: subhash.acharya@grandehospital.com
Phone: +977- 9851147242

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